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1Copyright © 2013. Pearson, Inc., and/or its affiliates. All rights reserved.

Advanced Clinical Solutions: Enhancing the Clinical Utility of WAIS-IV and WMS-IVGloria Maccow, Ph.D., Assessment Training Consultant

Advanced Clinical Solutions Advanced Clinical Solutions for WAISfor WAIS--IV and WMSIV and WMS--IVIV

Gloria Maccow, PhDAssessment Training Consultant

2 | Copyright © 2013. All rights reserved.

AgendaAgenda

• Describe components of Advanced Clinical Solutions for WAIS-IV and WMS-IV (ACSW4W4).

• Select components of ACSW4W4 to answer specific referral questions;

• Analyze data from ACSW4W4 to determine if cognitive abilities are declining; and

• Analyze data from ACSW4W4 to determine if examinee’s performance is consistent with the nature of the injury or clinical condition.



Advanced Clinical Solutionsfor WAIS-IV and WMS-IV

is an individually administered array of tests, procedures, and scores

addressing specific clinical questions and needs.


Primary Goal of ACS . . .Primary Goal of ACS . . .

To expand and enhance the clinical utility of WAIS-IV and/or WMS-IV through . . .




Applications of ACS . . .Applications of ACS . . .

additional assessments of:

– premorbid functioning– effort– social cognition– executive function

A separate instrument, Texas Functional Living Scale, linked with the WAIS-IV and WMS-IV, can be used to assess instrumental activities of daily living.


Applications of ACS . . .Applications of ACS . . .

and software that delivers:

– Demographically Adjusted Norms– Additional scores for WAIS-IV and WMS-IV– Reliable Change scores




Designed for Use . . .Designed for Use . . .

• in forensic settingsforensic settings to measure pre-morbid function (insurance claims) and suboptimal effort (malingering).

• with older adultsolder adults to assess current status, premorbid functioning, decline in cognitive functions, and reliable change.


Designed for Use . . .Designed for Use . . .

• with individuals who have traumatic brain traumatic brain injuryinjury to assess premorbid functioning, executive functions, and social cognition.

• with individuals with Autism/ Autism/ AspergerAsperger’’ssto evaluate social cognition.




Components of ACSComponents of ACS

Memory GridCardsWord Choice Stimulus BookRecord Forms/Booklets

Additional Assessments




PremorbidPremorbid FunctioningFunctioning

Test of Pre-Morbid Functioning (TOPF)

ʊ Revision of the Wechsler Test of Adult Reading (WTAR).

ʊ Provides an estimate of premorbidintellectual functioning.



Test of Pre-Morbid Functioning (TOPF)

– Revised and re-normed with WAIS–IV and WMS–IV.

ʊ Enhanced by the addition of more difficult words and an extended IQ range of predictability.




Test of Test of PremorbidPremorbid FunctioningFunctioning

• Uses Atypical Grapheme-Phoneme translation to measure word knowledge through reading.

• Relatively resistant to brain injury and dementia.



Premorbid Prediction Models– Demographics only (simple or complex)– TOPF only– Demographics with TOPF

Predict WAIS-IV Indexes and WMS-IV IMI, DMI, and VWMI




EffortEffort

Assessing Suboptimal Effort

— Help determine if the examinee’s level performance is consistent with the nature of his or her injury or clinical condition.

— Information on effort may be required for certain medical-legal and forensic evaluations.


EffortEffort

Assessing Suboptimal Effort• Available for Ages 16-69• External Measure

ʊ New subtest: Word Choice

• Embedded Measuresʊ Reliable Digit Spanʊ Logical Memory Recognitionʊ Verbal Paired Associates Recognitionʊ Visual Reproduction Recognition




Social CognitionSocial Cognition

Assessing Social Cognition

ʊ An assessment of an individual’s ability to understand non-verbal communication and social interactions.

ʊ Three new subtests (Social Perception, Faces -Supplemental, Names - Supplemental) provide assessments of emotion, face, and name recognition, as well as prosody and incidental recall of emotional expression. Audio files on CD-ROM.


Social Perception SubtestSocial Perception Subtest

Consists of 3 tasks– Affect Naming (Happy, Sad, Angry, Surprise,

Disgust, Fear, and Neutral)

– Prosody-Face Matching (includes Sarcasm)

– Prosody-Pairs Matching

� Listen to a pair of individuals interacting.

� Describe how tone of voice changes the meaning of what is said.




Executive FunctionExecutive Function

Assessing Executive Function with selected tests from Delis-Kaplan Executive Function System (D-KEFS)

Trail Making (Conditions 2, 3, & 4)ɔ Number Sequencing, Letter Sequencing, Number-

Letter Switching

Verbal Fluency

ɔ Letter and Category Fluency, Category Switching

Now correlated with WAIS–IV and WMS–IV


Verbal FluencyVerbal Fluency

Note- this is a language test. Deficits in executive functioning may be inferred if no significant language impairments are present.




Instrumental Activities of Instrumental Activities of Daily LivingDaily Living


About TFLSAbout TFLS

TFLS is a brief, ecologically valid, performance based measure to identify the level of care required by an individual.

Authors: Munro Cullum, PhD, Myron F. Weiner, MD, and Kathleen C. Saine, PhD.

Publication Date: April 2009




Overview of TFLSOverview of TFLS

• Brief assessment of functional competenceʊ 15 minutes to administerʊ Assesses Instrumental Activities of Daily Living

(IADL)

• Performance-based measureʊ Direct assessment of skills

• Designed for Ages 16-90


Use TFLS to . . . Use TFLS to . . .

– Assess functional abilities (Time, Money and Calculation Skills, Communication, Memory)

– Screen for dementia– Monitor functional decline– Monitor treatment/drug efficacy– Determine level of care required

Linked with WAIS-IV and WMS-IV




Interpretation of TFLSInterpretation of TFLSTotal Score T-Score metric combines all 4 domains.

– T-Score above 40 points suggests individual can live independently.

– T-Score below 25 points often suggests individual may need to reside in a special care unit.

– T-score of 26-40 (mild, mild-to-moderate, and moderate impairment) suggests individual may need partial or fully assisted living.

ACS SoftwareAdditional Scores




Demographically Adjusted NormsDemographically Adjusted Norms

• Enable clinician to refine hypothesis about the degree to which a specific score is unexpected when compared to individuals of similar background characteristics (e.g., education level).

• Norms approximate the unique demographic subgroup of an individual.



Available for WAIS-IV and WMS-IV Subtest and Index Scores

ɔ Education-only adjusted norms

ɔ Full Demographically adjusted norms




Use of Demographically Use of Demographically Adjusted NormsAdjusted Norms

• Meant to minimize the impact of psychosocial variables on the diagnosis of cognitive impairment, such as estimating the degree of cognitive impairment after a brain injury or insult.

• “. . . most appropriately applied in the context of a neurodiagnosticassessment.”



NOT a replacement or substitute for WAIS-IV or WMS-IV conventional age-adjusted norms. NOT to be used for:

9 psychoeducational evaluations,

9 determination of intellectual deficiency,

9 vocational assessment,

9 ..” any context in which the purpose of the evaluation is to determine the absolute functional level (IQ or Memory) of the examinee relative to a representative sample of the U.S. population” (The Psychological Corporation, 2002).




PremorbidPremorbid FunctionFunction• Software applies a regression equation to

predict premorbid abilities using demographic characteristics and/or performance on the ACS Test of PremorbidFunctioning (TOPF).

• Software Provides – Estimate of Premorbid IQ (FSIQ, GAI, VCI, PRI,

WMI, and PSI)

– Estimate of Premorbid Memory Ability (IMI, DMI, and VWMI)


Reliable ChangeReliable Change

• Assesses whether performance differences over time are due to actual changes in functioning, and not to the unreliability of the measure.

• Uses scores from the WAIS–IV and/or WMS–IV to compute a reliable change score between an assessment at Time 1 and Time 2.




Reliable ChangeReliable Change

• Software uses regression based models to provide an indicator of a significant decline in performance between test sessions controlling for the impact of practice effects, ability level, and age where appropriate.

• Available for all WAIS-IV and WMS-IV subtest and index scores.


Additional Subtest ScoresAdditional Subtest Scores

Allow better identification and description of the nature and extent of observed memory problems.

Additional WAIS-IV Subtest ScoresʊCancellation

Additional WMS-IV Subtest ScoresʊLogical MemoryʊVerbal Paired AssociatesʊDesignsʊVisual Reproduction




Additional Index ScoresAdditional Index Scores

WMS-IV Indexes– Auditory Immediate– Auditory Delayed– Auditory Recognition– Visual Immediate– Visual Delayed– Visual Recognition– Designs Spatial – Designs Content


Additional WMSAdditional WMS--IV Contrast ScoresIV Contrast Scores

AuditoryAuditoryɔ Immediate vs.

Delayed

ɔ Recognition vs. Delayed

VisualVisualɔ Immediate vs.

Delayed

ɔ Recognition vs. Delayed

Designs: Spatial vs. Content




SummarySummaryACS: Construct CoverageACS: Construct Coverage

Refined assessment of memory functions– Error scores– Additional indexes

Suboptimal Effort- Word Choice

- Embedded Measures

Social Cognition– Affect Recognition, Prosody

– Faces– Names

Executive Function– Trail-Making

– Verbal Fluency

Change in cognitive function

– Demographic Adjustments to Norms

– Premorbid Ability estimation

– Reliable Change Scores (regression based)

Are Cognitive Abilities Declining?




Many Factors can Influence Many Factors can Influence PerformancePerformance

– Acuity– Attention– Executive Functioning– Global Intellectual Functioning– Working Memory– Language Impairment (Auditory Memory subtests)– Visual-Spatial Processing (Visual Memory subtests)– Fatigue– Poor Effort– Impulsivity


Intake InformationIntake Information

• Mabel is an 82-year old female.

• She attended college but did not complete degree.

• She was married for 50 years until her husband died 10 years ago.

• She was a homemaker and never worked outside the home.




Referral ConcernsReferral Concerns

• Her children referred Mabel for evaluation.

• They are concerned about declines in her cognitive abilities and about her living alone.


Referral ConcernsReferral Concerns

According to her children,

– Mabel evidences word retrieval difficulties, and difficulty sequencing complex information.

– She is forgetful and easily overwhelmed with instrumental daily activities.




Intake InformationIntake Information

• Mabel is relatively physically healthy.

• She was diagnosed with atrialfibrilation and osteoporosis - both being treated with medication.

• She takes Namenda to treat cognitive decline.


Dementia or Dementia or Mild Cognitive ImpairmentMild Cognitive Impairment

Clinical concepts concerning this referral:

– Change in cognitive status from a previous level

– Mental Status

– Memory impairment

– Self-care

– Depression




Clinical QuestionsClinical Questions

Is Mabel experiencing dementia?– Does she evidence deficits in two or more

areas of cognition?

– Does she manifest a decline in memory and other cognitive functions relative to premorbid cognitive ability?

If cognitive abilities are impaired, what is the impact on daily living?


Procedures UtilizedProcedures Utilized

– WAIS-IV– WMS-IV + Brief Cognitive Status Exam

– ACS: Additional Scores– ACS: Test of Premorbid Functioning

– Reliable Change Scores (Serial Assessment)– Texas Functional Living Scales




Evaluation ResultsEvaluation Results

i Mini Mental Status Exam = 19 (middle stage/moderate Alzheimer’s disease)

i BDI-II=1 (no indication of depression)


CompositeCompositeClinical Clinical MeanMean

Control Control MeanMean

MeanMeanDiff.Diff. pp valuevalue

Effect Effect SizeSize

VCI 86.2 103.0 16.84 <.01 1.04

PRI 85.8 101.5 15.72 <.01 1.01

WMI 84.3 100.9 16.66 <.01 1.12

PSI 76.6 102.6 26.06 <.01 1.70

FSIQ 81.2 102.0 20.87 <.01 1.25

WAISWAIS--IV: Probable Dementia of IV: Probable Dementia of AlzheimerAlzheimer’’s Types Type--MildMild

n = 44






MeanMeanDiff.Diff. pp valuevalue


VCI 99.0 106.1 7.13 <.01 .49PRI 93.9 102.4 8.43 <.01 .61WMI 96.6 104.7 8.13 <.01 .54PSI 94.9 102.2 7.33 .05 .53FSIQ 94.8 104.8 10.00 <.01 .72

WAISWAIS--IV: IV: Mild Cognitive ImpairmentMild Cognitive Impairment

n = 53


Composite Score/ Index/Subtest Scaled Score


Verbal Comprehension 98 Perceptual Reasoning 92

Similarities 11 Block Design 9Vocabulary 10 Matrix Reasoning 9

Information 8 Visual Puzzles 8

Working Memory 97 Processing Speed 74

Digit Span 10 Coding 6

Arithmetic 9 Symbol Search 4

Full Scale IQ = 89 General Ability Index = 95

WAISWAIS--IV ScoresIV Scores




IndexIndex--Level Level Discrepancy ComparisonsDiscrepancy Comparisons

ComparisonScore

1Score

2 Diff.

Critical Value

.05

SignificantDifference

Y / N

Base RateOverall Sample

VCI - PRI 98 92 6 9.75 N 32.5

VCI - WMI 98 97 1 8.82 N 48.1

VCI - PSI 98 74 24 9.75 Y 7

PRI - WMI 92 97 -5 10.99 N 37.1

PRI - PSI 92 74 18 11.75 Y 12.1

WMI - PSI 97 74 23 10.99 Y 7.3

FSIQ - GAI 89 95 -6 3.19 Y 12.4


PSI: WeaknessPSI: Weakness

Mabel’s ability to mentally process routine information rapidly without making errors is a weakness relative to her verbal reasoning and nonverbal reasoning abilities.




PSI: Functional ImplicationPSI: Functional Implication

A weakness in the speed of processing routine visual information may make the task of comprehending novel and/or non-routine information more time-consuming and difficult for Mabel.


PSI: Functional ImplicationPSI: Functional Implication

A weakness in simple visual scanning and tracking may leave her less time and mental energy for the complex task of understanding new material.




WMSWMS--IV: Probable Dementia of IV: Probable Dementia of AlzheimerAlzheimer’’s Types Type--MildMild

n = 48 (ages 65-89)

WMS-IV Index

Clinical Mean

Control Mean

MeanDiff. p value

Effect Size

AMI 68.5 107.1 38.60 <.01 2.24

VMI 69.7 102.5 32.85 <.01 2.00

IMI 71.7 107.4 35.71 <.01 2.16

DMI 63.6 104.6 40.98 <.01 2.39

GAI 86.9 110.4 23.57 <.01 1.64


WMS-IV Index

Clinical Mean

Control Mean

MeanDiff.

p value Effect Size

AMI 89.9 105.6 15.65 <.01 1.05

VMI 89.3 102.1 12.84 <.01 0.89

VWMI 91.6 107.2 15.54 <.01 1.22

IMI 90.8 105.8 15.00 <.01 1.09

DMI 87.5 103.5 16.00 <.01 1.01

GAI 97.2 106.9 9.73 <.01 0.78

WMSWMS--IV: IV: Mild Cognitive ImpairmentMild Cognitive Impairment

n = 50 (ages 55-84)




WMSWMS--IV Scores: BCSEIV Scores: BCSE

i Mabel’s global cognitive functioning, as measured by the BCSE, was in the Lowrange, compared to others, ages 70 to 90, with a similar educational background.

i This classification level represents 2–4% of cases within her age and education group.


WMSWMS--IV Scores: BCSEIV Scores: BCSE

Functioning in this range has a moderately high probability of being considered atypical, though not necessarily diagnostic.




Index/Subtest Index Score/ Scaled Score

Index/Subtest Index Score/ Scaled Score

Auditory Memory 78 Visual Memory 66

Logical Memory I 9 Visual Reproduction I 3Logical Memory II 2 Visual Reproduction II 5

Verbal Paired Associates I 7

Verbal Paired Associates II 7 Symbol Span 6

Immediate Memory 77 Delayed Memory 67

Logical Memory I 9 Logical Memory II 2

Verbal Paired Associates I 7 Verbal Paired Associates II 7

Visual Reproduction I 3 Visual Reproduction II 5

WMSWMS--IV ScoresIV Scores


AbilityAbility––Memory AnalysisMemory Analysis

Ability Score Type: GAI (= 95)Predicted Difference Method

Index

Predicted WMS–IV

Index Score

Actual WMS–IV

Index Score Difference

Critical Value


Y / NBaseRate

Auditory Memory 97 78 19 9.33 Y

5-10%

Visual Memory 97 66 31 7.72 Y <1%

Immediate Memory 97 77 20 10.41 Y 4%

Delayed Memory 97 67 30 10.86 Y 1%




Retention of InformationRetention of Information

WMS–IV Indexes

Index Score 1 Score 2Contrast

Scaled ScoreImmediate Memory Index vs. Delayed Memory Index

77 67 5


Auditory Memory Relative Auditory Memory Relative to WAISto WAIS--IV AbilitiesIV Abilities

Contrast Scaled Scores

Score Score 1 Score 2Contrast

Scaled Score

General Ability Index vs. Auditory Memory Index

95 78 5

Verbal Comprehension Index vs. Auditory Memory Index

98 78 5

Working Memory Index vs. Auditory Memory Index

97 78 6




GAI vs. AMIGAI vs. AMIThe clinical groups that significantly differ from the controls and have large effect sizes on the GAI vs. AMI are– Probable Dementia of the Alzheimer’s

Type-Mild Severity, – Mild Cognitive Impairment, – Mild and Moderate Intellectual Disability, – Schizophrenia, and – Moderate-to-Severe TBI groups.


Auditory Process ScoresAuditory Process Scores

Auditory Memory Process Score Summary

ScoreRaw

ScoreScaled Score

Percentile Rank

Cumulative Percentage(Base Rate)

LM II Recognition 15 - - 17-25%

VPA II Recognition 22 - - 10-16%

VPA II Word Recall 5 7 16 -




Forgetting and Retrieval: Forgetting and Retrieval: Auditory ModalityAuditory Modality

Logical Memory


Scaled Score

LM II Recognition vs. Delayed Recall 17-25% 2 1

LM Immediate Recall vs. Delayed Recall 9 2 1


Forgetting and Retrieval: Forgetting and Retrieval: Auditory ModalityAuditory Modality

Verbal Paired Associates


Scaled ScoreVPA II Recognition vs. Delayed Recall 10-16% 7 9

VPA Immediate Recall vs. Delayed Recall 7 7 10




Visual Memory Relative Visual Memory Relative to Other Abilitiesto Other Abilities


Scaled Score

General Ability Index vs. Visual Memory Index

95 66 2

Perceptual Reasoning Index vs. Visual Memory Index

92 66 2


Visual Process ScoresVisual Process Scores

Visual Memory Process Score Summary

ScoreRaw

ScoreScaled Score

Percentile Rank

Cumulative Percentage(Base Rate)

VR II Recognition 2 - - 17-25%

VR II Copy 43 - - >75%




Forgetting and Retrieval: Forgetting and Retrieval: Visual ModalityVisual Modality

Visual Reproduction


Scaled Score

VR II Recognition vs. Delayed Recall

17-25% 5 6

VR Copy vs. Immediate Recall

>75% 3 2

VR Immediate Recall vs. Delayed Recall

3 5 8


ModalityModality--Specific Memory Specific Memory Strengths and WeaknessesStrengths and Weaknesses

WMS–IV Indexes

Index Score 1 Score 2Contrast

Scaled ScoreAuditory Memory Index vs. Visual Memory Index 78 66 5




Visual Working MemoryVisual Working Memory

Mabel’s ability to keep in mind a mental image of a symbol and its relative spatial position on the page is below average (Symbol Span scaled score = 6).


Immediate Memory Relative Immediate Memory Relative to WAISto WAIS--IV GAIIV GAI


Scaled Score

General Ability Index vs. Immediate Memory Index

95 77 4




GAI vs. IMIGAI vs. IMIThe clinical groups that significantly differ from the controls and have large effect sizes on the GAI vs. IMI are– Probable Dementia of the Alzheimer’s

Type-Mild Severity, – Mild Cognitive Impairment, – Mild and Moderate Intellectual Disability, – Right Temporal Lobectomy, – Moderate-to-Severe TBI groups, and– Autistic Disorder groups.


Delayed Memory Relative Delayed Memory Relative to WAISto WAIS--IV GAIIV GAI

ScoreScore

1Score

2Contrast

Scaled Score

General Ability Index vs. Delayed Memory Index

95 67 3




GAI vs. DMIGAI vs. DMI

The clinical groups that significantly differ from the controls and have large effect sizes on the GAI vs. DMI are– Probable Dementia of the Alzheimer’s

Type-Mild Severity, – Mild Cognitive Impairment, – Mild and Moderate Intellectual Disability, – Right Temporal Lobectomy, – Autistic Disorder, Schizophrenia, and – Moderate-to-Severe TBI groups.


Additional ScoresAdditional Scores--AMIAMI

WMS-IV Index

Index Score

Percentile Rank

Qualitative Description

Auditory Immediate 89 23 Low Average

Auditory Delayed 67 1 Extremely Low

Auditory Recognition 76 5 Borderline




Additional ScoresAdditional Scores--AMIAMI

Score Score 1 Score 2

Contrast Scaled Score

Auditory Immediate Index vs. Auditory Delayed Memory Index

89 67 1

Auditory Recognition Index vs. Auditory Delayed Memory Index

76 67 5



• Uses Atypical Grapheme-Phoneme translation to measure word knowledge through reading.

• Relatively resistant to brain injury and dementia.





• Premorbid Prediction Models– Demographics only (simple or

complex)

– TOPF only– Demographics with TOPF

• Predict WAIS-IV Indexes and WMS-IV IMI, DMI, and VWMI



Test of Premorbid Functioning Score Summary

Raw Score

Standard Score

Percentile Rank


Test of PremorbidFunctioning 61 119 89.7 High Average





WAISWAIS––IV Actual IV Actual –– Predicted ComparisonPredicted Comparison

Composite Actual Equated DifferenceCritical Value

Significant Difference

Base Rate

FSIQ 89 117 -28 6.11 Y 3.4%

VCI 98 117 -19 7.3 Y 9.3%

PRI 92 117 -25 11.12 Y 17.9%

WMI 97 118 -21 9.77 Y 16.1%

PSI 74 118 -44 11.04 Y 5.7%

Actual – Predicted Comparison based on Test of Premorbid Functioning Equated Model



WMS–IV Actual – Predicted Comparison

Index Actual Equated DifferenceCritical Value

Significant Difference

Base Rate

IMI 77 117 -40 9.65 Y 2.2%

DMI 67 118 -51 10.36 Y 3.9%

Actual – Predicted Comparison based on Test of Premorbid Functioning Equated Model




Reliable Change ScoreReliable Change Score

Used to determine if there has been a change in cognitive functioning between 2 time periods– Decline associated with dementia or other

progressive neurological condition– Improved function related to intervention

such as rehabilitation or medication effects



Applies multivariate hierarchical regression method to control for practice effects and other factors associated with change in performance.





Predictors– Time 1 performance

– GAI (or VCI or PRI)

– Age

– Education

– Sex

– Test interval



• Compare actual time 2 performance to predicted time 2 performance

– Statistically significant difference

– Base rate

• If difference is significant and rare, may indicate a decline or improvement in functioning.





Serial Assessment Report for WAIS-IV and WMS-IV Mabel Sample82

Test-Retest Interval 6 months 0 days


WAISWAIS--IV Serial AssessmentIV Serial Assessment




WMSWMS--IV Serial AssessmentIV Serial Assessment


Clinical QuestionsClinical Questions

Is Mabel experiencing dementia?

– Progressive and long-term decline in cognitive function.

– Perceptual reasoning ability, speed of processing visual information, and memory, especially long-term memory.




Diagnosis and TreatmentDiagnosis and Treatment

• Evaluate all data to determine if Mabel’s current functioning is consistent with a diagnosis of Dementia.

• Establish the impact of cognitive impairment on Mabel’s performance of instrumental activities of daily living?



Texas Functional Living Scale

ScoreTime Total

Money and Calculation

TotalCommunication

TotalMemory

TotalTFLS Total

Raw Score 8 6 26 3 43

Subscale Cumulative Percentage

51-75 17-25 26-50 3-9

TFLS T-Score 40





• Impairments in cognitive functions adversely impact Mabel’s ability to perform instrumental activities of daily living.

• T-score of 40 on the TFLS indicates mild impairment.


DiagnosisDiagnosis

• On initial assessment, Mabel’s performance indicated a possible decline in functioning from previous levels of performance with a clear memory impairment present.

• On re-evaluation, Mabel showed significant declines in general intellectual and memory functioning.




DiagnosisDiagnosis

• The data indicate a progressive and long-term decline in cognitive function.

• The clinician diagnosed Mabel with Alzheimer’s Disease.


Living ArrangementsLiving Arrangements

• It was determined that Mabel required an assisted living environment due to her significant difficulties with memory and daily functioning.

• Mabel was placed in an assisted living facility close to her children. She functioned relatively independently and did well with structured routines.




Interventions: EncodingInterventions: Encoding

• Given her relative strength in higher-order conceptualization and reasoning, Mabel may benefit from using associative linkages when encoding information.

• By linking new information to what has been previously learned, she may be able to gain a more global understanding of the information and improve recall.



• When she first encounters new information, she should link it in as many ways as possible to already known information.

• This strategy creates several avenues for remembering the information later.





• Encourage her to use external memory sources, for example, leaving verbal messages on her telephone answering machine, to remind herself to pay bills, take medication, schedule/keep appointments, etc.


Interventions: Interventions: Retention of InformationRetention of Information

To increase her ability to retain information, build on her relative strength in verbal comprehension.– Encourage her to verbalize the steps she

will use to complete a daily routine (e.g., dressing) or to complete an assigned task. This self-talk can reinforce the sequencing of all necessary steps for successful task completion.




Interventions: Interventions: Retention of InformationRetention of Information

To increase her ability to retain information, build on her relative strength in verbal comprehension.

– To complete extensive or complex tasks, ask her to break down these larger tasks into shorter, simpler tasks with feasible deadlines.


Interventions to Improve SkillsInterventions to Improve Skills

Her short-term memory and vocabulary skills could be improved at home while playing games that require memory, concentration, and recall of information.




Interventions to Improve SkillsInterventions to Improve Skills

• Computer-assisted educational programs may be of benefit to her.

• If she enjoys video games, learning can be integrated into this fun activity.

• Numerous commercial educational software packages exist to meet her needs.

Is Performance Consistent with the Nature of the Injury

or Clinical Condition?




Background InformationBackground Information

• Blake is a 23 year old, single, white male, with a bachelor’s degree in political science.

• In 2009, he was working as an assistant store manager when he sustained a moderate TBI as a result of a motor vehicle accident.

• Upon admission to the hospital, his Glasgow Coma Scale was 7.



• He sustained hemorrhagic contusions with depressed skull fracture in right frontal area.

• Blood was noted in anterior temporal tip.




Frontal LobeFrontal Lobe

Damage associated primarily with executive dysfunction – possible impaired flexibility in problem-solving or in adaptability (Lezak, et al., 2004).

http://www.neuroskills.com/tbi/bfrontal.shtml



• Blake’s orientation and language functions returned to normal after 3㵥4 hours.

• He experienced on㵥going headaches, sleepiness, and fatigue for several days.

• He was released from the hospital after 3 days.





• Blake continued to struggle with fatigue.

• He struggled to concentrate especially when reading.

• He returned to work after 3 weeks but had to leave early because of headaches and difficulty focusing and sustaining his attention.



• His parents encouraged Blake to seek legal counsel regarding the accident because the accident had been caused by a car whose driver had failed to stop at the red light.

• The lawyer observed that they had a good chance of winning a claim against the company given the on-going difficulties Blake was experiencing after the accident.





• As part of the legal case, Blake was sent for neuropsychological evaluation of ongoing attention problems.

• The evaluation was conducted 12 months post㵥injury.


Traumatic Brain InjuryTraumatic Brain Injury

– Acquired brain injury caused by external physical force

– May lead to temporary or permanent impairment of

� cognitive,

� physical, and

� psychosocial functions.

http://emedicine.medscape.com/article/326510-overview




Moderate TBIModerate TBI––Clinical ConceptsClinical ConceptsTBI associated with deficits in– memory (including working memory)– attention/executive functioning– processing speed– theory of mind and social perception (more

recently)– language problems – perceptual problems

See TBI special group studies in WAIS-IV and WMS-IV Technical and interpretive manual.


Moderate TBIModerate TBI––Clinical ConceptsClinical Concepts

• Higher-level cognitive skills, commonly referred to as executive functions, have been ascribed primarily to dorsolateralprefrontal regions.

• Emotional and behavioral regulation and control have been attributed primarily to ventromedial prefrontal cortex.




Moderate TBIModerate TBI––Clinical ConceptsClinical Concepts

• Loss of cognitive functioning from a previous level.

• Secondary gain introduced by the medical㵥legal case against the company responsible for the accident.

• Medical evidence for the presence of a moderate TBI.


Procedures UtilizedProcedures Utilized

– Record Review

– Clinical Interview

– WAIS㵥IV

– WMS㵥IV

– ACS: Demographically Adjusted Norms

– D㵥KEFS: Trail Making, Verbal Fluency

– ACS: Social Perception

– ACS: Suboptimal Effort




Moderate TBI and CognitionModerate TBI and Cognition

• Is there evidence of impairment in general cognitive functioning?

• Is there evidence of a deficit in memory?


TBI and WAISTBI and WAIS--IVIV

n = 22



MeanMeanDiff.Diff.

ppvaluevalue


VCI 92.1 100.8 8.73 .03 .52

PRI 86.1 100.7 14.64 <.01 .94

WMI 85.3 97.9 12.59 <.01 .78

PSI 80.5 97.6 17.09 <.01 .97

FSIQ 83.9 99.4 15.50 <.01 .93






Verbal Comprehension 114 Perceptual Reasoning 98

Similarities 13 Block Design 10

Vocabulary 13 Matrix Reasoning 9

Information 12 Visual Puzzles 10

Working Memory 100 Processing Speed 102

Digit Span 10 Coding 10

Arithmetic 10 Symbol Search 11

Full Scale IQ = 105 General Ability Index = 106

WAISWAIS--IV ScoresIV Scores


IndexIndex--Level Discrepancy Level Discrepancy ComparisonsComparisons

Comparison Score 1 Score 2 DifferenceCritical

Value .05


Y / N

Base RateOverall Sample

VCI - PRI 114 98 16 9.29 Y 12.2

VCI - WMI 114 100 14 10.18 Y 14.1

VCI - PSI 114 102 12 10.99 Y 22.2

PRI - WMI 98 100 -2 10.99 N --

PRI - PSI 98 102 -4 11.75 N --

WMI - PSI 100 102 -2 12.46 N --

FSIQ - GAI 105 106 -1 3.5 N --




What is the GAI?What is the GAI?

• The WAIS–IV GAI provides the practitioner with a summary score that is less sensitive than the FSIQ to the influence of working memory and processing speed.

• GAI = sum of scaled scores for VCI subtests and PRI subtests.


What is the GAI?What is the GAI?

• WAIS–IV GAI should be used for discrepancy comparisons

– Ability and Memory

– Ability and achievement

• GAI is NOT a replacement for FSIQ




General Ability IndexGeneral Ability IndexConsider*Consider* using the GAI if a significant and unusual discrepancy exists between

9 VCI and WMI; or 9 PRI and PSI; or9 WMI and PSI, or9 between subtests within WMI and/or PSI.

Note: The FSIQ is the most valid measure of overall cognitive ability and WM and PS are vital to comprehensive evaluation of cognitive ability.


General Ability Index General Ability Index -- Note!Note!• The GAI is used when neuropsychological deficits

adversely impact performance on WM and PS.

• Impaired performance on WM and/or PS may mask actual differences between general cognitive ability (FSIQ) and other cognitive functions (e.g., memory).

• The GAI does not replace the FSIQ. Report and interpret GAI along with FSIQ.

[see WAIS-IV Technical Manual]




Moderate TBI and Ability (WAISModerate TBI and Ability (WAIS--IV)IV)

• Relative to others his age, Blake’s intellectual functioning is within the Average range.

• Verbal comprehension is a strength relative to perceptual reasoning, working memory, and processing speed.


TBI and WMSTBI and WMS--IVIV n = 32 (ages 19n = 32 (ages 19--45)45)

IndexIndexClinical Clinical MeanMean


MeanMeanDiff.Diff.

ppvaluevalue


AMI 80.0 101.0 21.00 <.01 1.25

VMI 82.5 101.2 18.64 <.01 1.07

VWMI 85.5 104.6 19.06 <.01 1.26

IMI 80.7 102.2 21.53 <.01 1.24

DMI 77.8 100.4 22.64 <.01 1.24

GAI 92.2 104.8 12.65 <.01 .92




Index Score/ Index/Subtest Scaled Score


Auditory Memory 105 Visual Memory 96

Logical Memory I 13 Visual Reproduction 10

Logical Memory II 16(S) Visual Reproduction II 10

Verbal Paired Associates I 7(W) Designs I 8

Verbal Paired Associates II 8(W) Designs II 10

Visual Working Memory 100

Spatial Addition 12

Symbol Span 8





Immediate Memory 96 Delayed Memory 107

Logical Memory I 13 Logical Memory II 16

Verbal Paired Associates I 7 Verbal Paired Associates II 8

Visual Reproduction I 10 Visual Reproduction II 10





Moderate TBI and MemoryModerate TBI and Memory

• On WMS-IV, all index scores are in the average range.

• Delayed memory is a strength relative to Immediate Memory (contrast scaled score = 14).

• Scores on memory indexes are average relative to general ability.

• Note relative weakness for VPA I and VPA II and relative strength for LM II.


AbilityAbility––Memory AnalysisMemory Analysis

Predicted Difference Method: GAI = 106Predicted Difference Method: GAI = 106

IndexIndex

Predicted Predicted WMSWMS--IV IV

Index ScoreIndex Score

Actual Actual WMSWMS––IV IV

Index ScoreIndex Score Diff. Diff. Critical Critical ValueValue

Sign. Sign. Diff. Diff. Y / NY / N

BaseBaseRateRate

AMI 103 105 -2 9.35 N --

VMI 104 96 8 8.95 N --

VWMI 104 100 4 10.61 N --

IMI 104 96 8 9.78 N --

DMI 103 107 -4 9.57 N --




Moderate TBIModerate TBI

• Is this profile atypical for Blake’s education level?

• Is there evidence for loss of cognitive functioning.

Use Demographically Adjusted Norms



• Enable clinician to refine hypothesis about the degree to which a specific score is unexpected when compared to individuals of similar background characteristics (e.g., education level).

• Norms approximate the unique demographic subgroup of an individual.





Available for WAIS-IV and WMS-IV subtest and index scores.– Education-only adjusted t-scores.

– Full Demographically adjusted t-scores.



• Meant to minimize the impact of psychosocial variables on the diagnosis of cognitive impairment, such as estimating the degree of cognitive impairment after a brain injury or insult.

• “ . . . most appropriately applied in the context of a neuro-diagnostic assessment.”




WAISWAIS--IV DANIV DAN

WAIS-IV Education Adjusted Composite Score Summary

Age AdjustedAge Adjusted Education AdjustedEducation Adjusted

CompositeCompositeComposite Composite

ScoreScorePercentile Percentile

RankRank T Score T Score Percentile Percentile

RankRankQualitative Qualitative DescriptionDescription

VCI 114 82 55 69.1Above

Average

PRI 98 45 44 27.4 Low Average

WMI 100 50 45 30.9 Average

PSI 102 55 48 42.1 Average

FSIQ 105 63 48 42.1 Average

GAI 106 66 49 46.0 Average

WAISWAIS--IV DANIV DANWAIS–IV Education Adjusted Subtest Score Summary

Age Adjusted Education Adjusted

Subtest Scaled Score

PercentileRank

T Score

PercentileRank


Similarities 13 84 57 75.8 Above Average

Vocabulary 13 84 55 69.1 Above Average

Information 12 75 52 57.9 Average

Block Design 10 50 47 38.2 Average

Matrix Reasoning 9 37 43 24.2 Low Average

Visual Puzzles 10 50 49 46.0 Average

Digit Span 10 50 47 38.2 Average

Arithmetic 10 50 46 34.5 Average

Symbol Search 11 63 50 50.0 Average

Coding 10 50 47 38.2 Average





WMSWMS--IV DANIV DAN

WMS-IV Education Adjusted Index Score Summary

Age AdjustedAge Adjusted Education AdjustedEducation Adjusted

IndexIndexIndex Index ScoreScore

Percentile Percentile RankRank T Score T Score

Percentile Percentile RankRank

Qualitative Qualitative DescriptionDescription

AMI 105 63 52 57.9 Average

VMI 96 39 45 30.9 Average

VWMI 100 50 47 38.2 Average

IMI 96 39 44 27.4 Low Average

DMI 107 68 52 57.9 Average

WMSWMS--IV DANIV DAN

WMS–IV Education Adjusted Subtest Score Summary

Age Adjusted Education Adjusted

Subtest Scaled Score PR

T Score PR


Logical Memory I 13 84 58 78.8 Above Average

Logical Memory II 16 98 69 97.1 Above Average

Verbal Paired Associates I 7 16 38 11.5 Mild Impairment

Verbal Paired Associates II 8 25 41 18.4 Low Average

Designs I 8 25 41 18.4 Low Average

Designs II 10 50 49 46.0 Average

Visual Reproduction I 10 50 48 42.1 Average

Visual Reproduction II 10 50 48 42.1 Average

Spatial Addition 12 75 54 65.5 Average

Symbol Span 8 25 42 21.2 Low Average





What do we know about Moderate to What do we know about Moderate to Severe TBI and WAISSevere TBI and WAIS--IV/WMSIV/WMS--IV/ACSIV/ACS

Executive FunctioningD-KEFS Trail Making Test

Ɇ Trail Making Letter and Number Sequencing 6.5

Ɇ Number-Letter Switching Time 7.1Ɇ Number-Letter Switching Errors 11.0

Also see Yochim, B., Baldo, J., Nelson, A., & Delis, D. (Jul 2007). D-KEFS trail

making test performance in patients with lateral prefrontal cortex lesions. Journal of the International Neuropsychological Society, 13(4), 704-709.


Trail MakingTrail Making

D-KEFS Trail Making - BlakeɆ Visual Scanning SS = 10Ɇ Number Sequencing SS = 7Ɇ Letter Sequencing SS = 8Ɇ Number-Letter Switching SS = 6Ɇ Number-Letter Switching Errors SS = 10Ɇ Motor Planning SS = 9




What do we know about Moderate to What do we know about Moderate to Severe TBI and WAISSevere TBI and WAIS--IV/WMSIV/WMS--IV/ACSIV/ACS

• Executive FunctioningD-KEFS Verbal Fluency

Ɇ Letter Fluency 7.6Ɇ Category Fluency 6.7Ɇ Category Switching Total Correct 7.0Ɇ Category Switching Total Accuracy 8.1


Verbal FluencyVerbal Fluency

D-KEFS Verbal Fluency - BlakeɆ Letter Fluency SS = 11Ɇ Category Fluency SS = 9Ɇ Category Switching SS = 8Ɇ Category Switching Accuracy SS = 8Ɇ Set Loss Error SS = 10Ɇ Repetitions SS = 9




Moderate TBI Moderate TBI –– Executive Executive FunctioningFunctioning

Are there deficits in executive functioning?Ɇ Trail Making: low-average scores for number

sequencing and switching.Ɇ Cannot determine if the problem is executive

functioning or slow processing speed.

Ɇ Verbal Fluency: scores in the average range.


Moderate TBI Moderate TBI –– Social PerceptionSocial Perception

Is there a deficit in social perception?

Social Perception has 3 tasks:– Affect Naming (Happy, Sad, Angry,

Surprise, Disgust, Fear, and Neutral)

– Prosody㵥Face Matching (includes Sarcasm)

– Prosody㵥Pairs Matching




What do we know about Moderate to Severe What do we know about Moderate to Severe TBI and WAISTBI and WAIS--IV/WMSIV/WMS--IV/ACSIV/ACS

Holdnack & Drozdick (2009). Social Perception Deficits after Moderate to Severe Traumatic Brain Injury. www.psychcorp.com


Moderate TBI Moderate TBI –– Social PerceptionSocial PerceptionIs there a deficit in social perception?– Scores range from low average to average

with 3 of 4 scores at 1sd below mean.– Compared to intellectual functioning,

social perception scores were low average.

– Observationally, he made errors mostly on incongruent items, particularly sarcasm.




Symptom Exaggeration?Symptom Exaggeration?

• What if the test results were exaggerated in order to gain an advantage in the law suit?

• Use ACS effort assessment to help determine if suboptimal effort issues should be considered.


Suboptimal EffortSuboptimal Effort

Criteria for definite malingering, neuro-cognitive deficit:– Presence of substantial external

incentive,– Definitive negative response bias, and– The response bias is not accounted for by

psychiatric, neurological, or developmental factors (Slick, Sherman, and Iverson, 1999).




Assessing Suboptimal EffortAssessing Suboptimal Effort

• ACS Word Choice• WAIS㵥IV Reliable Digit Span• WMS㵥IV– Logical Memory Delayed Recognition– Verbal Paired Associates Delayed Recognition– Visual Reproduction Delayed Recognition

[Available for ages 16㵥69]


Word ChoiceWord Choice1. Examinee sees and hears 50 words in

succession.

2. Examinee identifies each word as either man-made or natural.

3. Examinee sees card with 50 pairs of words and selects word that was previously presented from each pair.




Suboptimal EffortSuboptimal Effort

• Use at least 3 indicators.• Require at least 2 indicators at or below

cut㵥off when using low cut㵥offs (e.g. 10%).

See Effort Assessment Score Report Blake Sample 23.


Moderate TBI Moderate TBI -- ConclusionsConclusions

• Is this protocol indicative of suboptimal effort? No

• Overall conclusions– Blake suffered a moderate/severe TBI as

documented by medical records.

– Relative to his verbal comprehension abilities, he demonstrated a weakness on measures of perceptual reasoning, working memory, and processing speed.




Moderate TBI Moderate TBI -- ConclusionsConclusions

• Overall conclusions– His memory abilities are average

compared to his general ability.

– Interpretation of Blake’s performance on the Auditory Memory index should account for the variability of the subtest scores.


AMI AMI –– Score VariabilityScore VariabilityThe clinical relevance of the score variability on the AMI should be addressed in terms of Blake’s

– premorbid abilities,

– demands in his current environment,

– other co㵥occurring physical factors (e.g., recent onset of auditory acuity difficulties or physical impairments), or

– emotional status (e.g., depression, anxiety).




Moderate Moderate –– TBI ConclusionsTBI Conclusions

Overall conclusions– Acquired brain injury as a result of a MVA.

– Demonstrated weaknesses in switching mental set (executive function) and in social perception. These characteristics are consistent with known effects of brain injury.� Frontal lobe damage can impair cognitive flexibility.

� Injury to anterior temporal region can produce deficits in affect labeling, recognition of emotion, theory of mind.


RecommendationsRecommendations• It may be necessary to give Blake very specific

routines for work completion. For example, he should be told where to put materials, what to do if he does not understand the assignment, and what to do with the assignment once complete.

• Blake should be set well-defined time limits for task completion, so that tasks are completed in a timely manner. Blake should be allowed to monitor his own progress with a timing device.




RecommendationsRecommendations

• Blake should be taught to use a problem-solving approach to behavioral situations. Steps should involve Blake determining the best possible option for his behavior, choosing a problem-solving strategy, and evaluating the outcome.

• Concrete examples should be used to teach the approach (e.g., “What should you do if you are trying to concentrate on your work and another person begins talking to you?”).


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